Inspection on 28/07/06 for Alexandra House

This inspection was carried out on 28th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexandra House 17/06/08

Alexandra House 19/06/07

Alexandra House 15/11/05

Alexandra House 08/06/05

Alexandra House 06/01/05

Alexandra House 09/08/04

Alexandra House 10/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Alexandra House Masons Court Hillborough Road Solihull West Midlands B27 6PF Lead Inspector Lisa Evitts Unannounced Inspection 28th July 2006 09:25 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address Masons Court Hillborough Road Solihull West Midlands B27 6PF 0121 245 1081 0121 707 1090 leslie.robinson@sjmt.org.uk www.sjmt.org.uk Sir Josiah Mason’s Trust Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Hilary Lloyd Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Alexandra House is a registered care home for older people. The home is located on the outskirts of Solihull, in a residential area, close to local amenities and a bus service, which provides access to surrounding areas. The home is a single storey building, registered for thirty-six beds; all rooms are for single occupancy. The home has two lounges; two areas for dining and a conservatory, there are four assisted bathrooms and one walk in shower room available plus toilets within close proximity to communal areas, these meet the needs of residents living at the home. There is level access for wheelchair users to the front entrance and throughout the home. Corridors are wide and spacious and allow residents to move around the home freely and safely. The home has hoisting equipment available for residents who have decreased mobility. An accessible well maintained garden area with a pond is provided. The home is approached through security gates where there is ample parking for visitors, alternatively there is ample off road parking. The organisations head office is on site, the complex also provides sheltered housing and domiciliary care from separate facilities. Copies of the previous reports written for the home are available from the manager upon request, and there is a notice to advise visitors of this on the notice board. Inside the home, the reception area has notice boards, which display information about forthcoming events and other articles that may be of interest. The current charge for living at the home is £334 per week. Additional charges include chiropody, hairdressing, newspapers and phone rental. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was undertaken by one inspector over one full day and was assisted throughout by the Registered Manager. There were 34 residents living at the home on the day of the visit and two residents were receiving hospital treatment. Information was gathered from speaking to residents, staff and visitors and from observing staff perform their duties. Care and health and safety records were reviewed along with medication procedures. Staff files were sampled and a partial tour of the building and gardens was undertaken. Prior to the inspection the manager had completed a pre inspection questionnaire and returned it to CSCI, and this gave some information about the home, staff and residents that was taken into consideration. Two immediate requirements were made on the day of the fieldwork visit and a satisfactory response to these was received from the Chief Executive a week after the inspection took place. What the service does well: The home provides prospective residents with a range of information and an opportunity to visit the home to enable them to make an informed decision about whether they would like to live at the home. Comprehensive pre admission assessments are undertaken and this enables all residents to know before admission that their individual care needs could be met at the Home. Residents are offered a choice of meals and special diets are catered for. Residents are well supported by the care staff to meet their health, welfare and personal needs. Residents are able to exercise their choice over their daily lives and this promotes independence and individuality, they can have a key to their bedroom door if they wish. Personal allowances can be safely held by the home if requested by the residents. The home has 100 of staff qualified to NVQ Level 2 in care and this ensures that a skilled workforce cares for residents. Comments from residents and visitors included: “I couldn’t change anything, we are alright here” “I’m happy here” Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 6 “Why wouldn’t you not like it here, there’s nothing to dislike” “Mom is always clean and well presented” “I like to go to the church service” “I don’t see any activities happening” “Food isn’t bad, there’s plenty to choose from” “I’m very well looked after” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 The quality outcome of this area is excellent. This judgement has been made using available evidence including a visit to the service. The home provides prospective residents and their representatives with relevant information about the home, and this enables them to make an informed decision about the homes suitability. Residents are issued with a contract to ensure that they are informed of terms and conditions of their stay at the home. The home completes assessments and gathers pre admission information and this enables the home to ensure they can meet the needs of the prospective resident. Residents are invited to spend a day at the home, enabling them to make a choice about whether or not they may wish to live in the home. EVIDENCE: The home has a service user guide and statement of purpose, which contain relevant information about the home. These are not currently available in any other format and it is recommended that the home considers use of large print and audiotapes to ensure that people who have sensory impairments can also Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 9 access the information required in order to make an informed decision about the homes suitability. A current registration and liability insurance certificate are on display in the reception area of the office and this ensures that anyone using the premises can see them. Each resident is issued with a statement of terms and conditions of residency and this includes the room number to be occupied and fee. The home has a four-week trial period that gives the resident time to experience living at the home in order to help them to decide if they would like to stay as a permanent resident. Comprehensive pre admission assessments are completed prior to the resident being admitted into the home and this ensures that the home is able to meet the needs of the resident. The pre admission assessments enable the home to identify if any specialist equipment is required in order to ensure it is in place prior to admission ensuring that needs can be met. Residents are encouraged to visit the home and have a meal prior to making a decision about whether they would like to live there. Representatives are able to view the home on behalf or residents and a relative stated, “ I came and had a look around before mom came, there were two vacancies and I had a choice of room for mom”. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to the service. Resident’s health and personal care needs were well met by the care staff. Care plans provide staff with specific details to follow to meet the identified needs of the residents with the exception of aggressive behaviour and this may prevent them from receiving the specific care that they require. The management of medication is good and this ensures that residents receive their medication safely. EVIDENCE: Each resident has a care plan written. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the resident to maintain their needs. Three care plans were reviewed and it was pleasing to see that further improvements had been made to the care planning system since the last visit to the home and care plans provided more detail for staff to follow and included personal preferences. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 11 Some care plans had more than one identified need and gave an overview of the care required. It was recommended that these be changed into a summary and then individual care plans written with specific details. One file identified that a resident displayed aggressive behaviour at times and it is required that a behaviour chart is implemented and a care plan which identifies any trigger factors and details for staff to follow if the resident becomes abusive. From this the staff may be able to identify any trends in behaviour or triggers, which they could avoid in the future to minimise the risk of the behaviour being repeated. Since the last visit to the home, a biographical social history has been written for individual residents and these were found to be very detailed about the resident’s life and interests which provided the staff with information of interest to discuss with the residents and was beneficial when planning care. Care plans are generally evaluated on a monthly basis and there was evidence that family members had been involved by comments that were documented by staff. This ensures that the staff at the home maintain daily routines, likes and dislikes of the residents. Identity photographs were not available for all the residents at the home and this is required to ensure safety when administering medication or if needed should a resident leave the home unescorted and without staff knowledge. There was evidence of visits from external professionals such as GP, chiropodist, physiotherapist and district nurses. This ensures residents have access to care from specialists as required. Falls risk assessments are completed and showed changes in residents needs, for example one file clearly stated that the resident now required the use of a Zimmer frame. This ensures that staff are aware of changing needs and equipment required to minimise the risk of falls. Monthly weights and nutritional assessments are recorded to ensure that residents are not losing weight. One resident had been refusing to be weighed but this had not been documented and staff must record this information. Where they refuse to be weighed it is recommended that staff measure arm circumference if the resident agrees, in order to monitor weight gain or loss. Key workers write monthly reviews some of which were very detailed. Some reviews however had limited information and the manager must address this with the individual staff members. Residents were well presented and were appropriately dressed for the time of year. One relative spoken to said, “Mom is always clean and well presented” Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 12 Daily records were found to be very detailed and included information about visitors, visits from external healthcare professionals, changes in condition and details of how the residents had spent their day. The management of medication was generally good, with the exception of one resident’s medication that had not been signed in for upon receipt and there is no carry forward system in place, which does not enable an audit trail to be followed. Photocopies of prescriptions are kept in order for staff to check they have received the correct prescription from the pharmacy. Variable dose medications were recorded to ensure that staff could determine how much medication the resident had received. Fridge temperatures are recorded to ensure that medications are stored appropriately within their product licences. The Controlled Drugs register was checked and whilst the balances were correct, staff had not completed the balance correctly in the book, for one resident. The manager had already found this discrepancy and was in the process of speaking with staff about the error. Two signatures were available for all administrations. The manager has not completed drug audits since May to ensure staff competence due to lack of time, since the deputy manager moved. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in, which promotes their independence and individuality. Residents receive a varied and wholesome diet, which meets any specific dietary needs. EVIDENCE: There are a range of activities on offer should the residents wish to participate in them and this includes music to movement, scrabble, bingo, whist and quizzes. The hairdresser comes twice a week and staff give residents manicures. A church service is offered once a month for residents who wish to take part and one resident said “I like to go to the church service”. There was a notice board in the main lounge, where all the activities on offer are displayed. Some of the activities on offer take place at different homes on site and this encourages independence and the opportunity for residents to mix with other people outside of their home, to maintain interests. An Easter bonnet parade had taken place and photographs were available to demonstrate this. A summer fare and an open day were planned along with a Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 14 family day. Currently no residents attend any clubs, but go out with family members as they choose. Staff spoken to felt that time for activities, and activities offered were limited since the deputy manager had left the home. One member of staff said “the residents don’t go out very often” and another staff member said, “The residents could do with a bit more entertainment” Comments from relatives included: “I don’t know what activities they have” “I don’t see any activities happening” The manager must review the amount of time delegated to activities and review the activities offered to ensure that residents are stimulated. The recording of activities participated in requires further development to ensure they are recorded for the individual resident. The home has an open visiting policy and there is an option for relatives to join the residents for a meal at an additional cost, the home request that these are booked in advance where possible. Lunch was observed and staff were assisting residents in a respectful manner. Tables were attractively laid and cold drinks were available. Residents are asked each morning by the manager what they would like to eat and choices are offered. Menus are on a four weekly cycle. A record of food eaten by the residents is maintained and showed that residents can have an alternative to the main meals on the menu. Home made soups and cakes are on the menu and the kitchen staff also participated in the recent nutritional training, and has made changes to some ingredients to ensure that residents receive a nutritious and balanced diet. Special diets are available for reasons of health or cultural preferences. A comment in the compliment/complaint book said, “Lunch was excellent today” Other comments from residents included: “Food isn’t bad, there’s plenty to choose from” “Food is lovely” “I’ve eaten all the food” At teatime a resident was given sandwiches and he stated that he didn’t like them. It was pleasing to see that staff sought an alternative for the resident and came back with a hot meal, which suited the resident’s needs. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to the service. The complaints procedure is comprehensive and accessible to residents should they need to make a complaint. The home has systems in place to protect residents from abuse. EVIDENCE: The home has a comprehensive complaints procedure in place and this was on display in the lounge and is included in the service user guide. This ensures that it is accessible to residents and their representatives should they need to make a complaint. The home has not received any formal complaints since the last inspection and CSCI have not received any complaints pertaining to Alexandra House. Since the last fieldwork visit the manager has implemented a ‘grumbles log’ to record any informal complaints. The home had recorded four grumbles and these had been resolved to the satisfaction of the residents. Actions taken and outcomes had been recorded to provide an audit trail. One resident stated “I’ve got no complaints” and a relative said “If I had any complaints I would see the team leader on shift and if need be would ring the manager on the daytime” Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 16 Details for an advocacy service are given to residents as part of the service user guide and this is commendable as such services assist residents and their families to exercise personal autonomy and choice over their lives. The adult protection policy required amendments and the Registered Manager sent a revised policy to CSCI following the fieldwork visit. The policy is now in line with the local multi agency guidelines and shows that the organisation is keen to address areas where improvements are required in a timely manner. The home has a copy of the local Multi agency guidelines for reference. The home has a Whistle blowing policy to ensure that staff have the knowledge to protect clients/service users without fear of any reprisals. Staff have recently had training in adult abuse prevention and challenging behaviour and this ensures that staff have the knowledge to safeguard the residents from harm. One member of staff was able to give a very detailed response about how they would deal with an allegation of abuse. Another member of staff spoken to did not give a comprehensive response and was not aware of the Whistle blowing policy. It is required that all staff receive training on the Whistle blowing policy in order to ensure that they have the knowledge to protect residents without fear of any reprisals. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to the service. Alexandra House provides a homely, safe and comfortable environment in which residents are relaxed and secure. EVIDENCE: The home has two lounges and two areas for dining, all of which are decorated to a high standard, with the exception of some wall paper in the dining area which was lifting and needed repair. The carpet in the dining area was stained and required a deep clean, staff stated that it is deep cleaned once every couple of months but due to the volume of traffic through the dining area, more regular cleaning is required. The carpet in the conservatory required stretching as had ‘bubbled’ and could pose a potential trip hazard. The conservatory has ramped access with handrails to the garden area. The garden area is pleasant and has a large fishpond, which has just had a rail, put around to minimise the risk of anyone falling into the pond. There are a range Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 18 of chairs and benches available for residents to use and enjoy the garden area, weather permitting. The corridors around the home are wide and have handrails available to assist residents who have decreased mobility. The home has two assisted shower facilities and two assisted baths, which were in full working order and meet the needs of residents living at the home. Communal toilets have raised toilet seats and handrails to assist residents. Liquid soap and paper towels were available in communal toilets to prevent the risk of infection occurring. Resident’s bedrooms seen were personalised and this ensures that the residents feel at home in their surroundings. Bedrooms all are supplied with a television and telephone points are available if the residents choose to have their own phone installed. All rooms have a lockable facility and residents have the option of a key to their bedroom door to maintain their privacy. A relative said, “Moms room is lovely”. The home was clean and odour free on the day of the fieldwork visit, and this ensures a comfortable environment for residents to live in. A hygienic and effective system for the laundry of residents’ personal clothing and bed linen was in place. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels are maintained at the home to meet the identified needs of the residents. Information was not available to determine that staff had the appropriate checks before starting work and this does not ensure that residents are safeguarded. Staff undertake relevant training to ensure that they are competent to do their jobs. EVIDENCE: Staffing levels have been maintained at the home since the last fieldwork visit and there are no staff vacancies. Domestic, laundry and maintenance staff support care staff. The home has used some agency staff to cover for the holiday period and tries to keep to the same staff from the agency to ensure continuity for the residents of the home. The Registered Manager provides on call support to the person in charge of the shift, however this is not recorded on the staffing rotas. The arrangements for the on call support need to be reviewed to ensure that the Registered Manager has some free time when she is not on call. Comments from residents included: “They are very good here” “I’m very well looked after” “They look after you very well” Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 20 A relative stated, “Everyone I have met are excellent” All care staff at the home has achieved NVQ Level 2 in care and nine staff are enrolled to progress onto level 3. This means that the home has 100 achievement for staff and ensures that a skilled workforce is caring for residents in the home. One relative said, “I was impressed that 100 of staff had NVQ Level 2” Three staff files were reviewed; POVA first checks were not available on two of the files and the manager was unable to access the Criminal Records Bureau checks. An immediate requirement was made that POVA first checks must be available on staff files and CRB checks must be accessible to inspectors, the organisation responded to the requirement and the systems put in place will be assessed at the next fieldwork visit. Interview notes were available on some files but not all. Two references were seen, including references from current or most recent employer. There was evidence that staff have received training in fire, manual handling, food hygiene, Dementia and Challenging behaviour, Parkinson’s awareness, Control of substances hazardous to health, Health and Safety and nutrition. This ensures that staff continue to update their knowledge and skills and have the competence to meet the residents needs. An induction checklist had been completed over four days, the booklet was the TOPPS training pack and the manager must ensure that induction is in line with the Skills for Care induction. A second file showed that induction training had not been completed and the manager must ensure that induction training is completed to ensure that staff have basic knowledge of their job role. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. The home must develop a quality assurance system to ensure a consistent improving standard. There is a robust system in place for the management of resident’s personal finances. Improvements are required to ensure that health, safety and welfare of the residents is maintained. EVIDENCE: The Registered Manager has had much experience in caring for older people and continues to undertake training and this shows she is keen to continue to learn and develop new skills in order to care for residents at the home. Recently she completed training courses for appraisals and supervisions, care planning, nutrition, dementia and challenging behaviour and policies and procedures. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 22 Since the last fieldwork visit to the home the manager no longer has a deputy and while there is evidence of improvements within the home, the manager requires continued support to make and to sustain improvements already in place, whilst being assisted with the overall running of the home. The manager is responsible for all the care plans at the present time and has not completed drug audits since May due to lack of time. The senior managers must review the current workload and identify how this can be allocated to other staff in order to enable the manager to concentrate on her role. Regulation 26 visit reports have not been received by CSCI since the new Director has taken over Alexandra House and this was brought to the attention of the manager. No reports were available for review on the day of the fieldwork. The Director must ensure that Regulation 26 reports are written and are available for review by CSCI in order to evidence a consistently improving service is being provided by the home. The home has no formal quality assurance system in place, however had arranged for an external company to come into the home and advise. At the time of the last fieldwork visit the home had purchased a quality assurance system but no work had been undertaken on this. A formal quality assurance system is required in order to show that the views of residents, representatives, staff and external stakeholders have been considered and an action plan devised to ensure a consistently improving service is being provided. No resident meetings had been held and there were no minutes available from a staff meeting held while the manager was on holiday. Meetings must take place and minutes recorded to ensure that residents, families and staff are given the opportunity to discuss and share any ideas or concerns in an open and inclusive atmosphere. The home holds personal monies for 19 residents, a sample of these was reviewed and balances were found to be correct. Each resident has their own record of credits and debits and receipts were available for monies spent. Audits were completed however it is recommended that these are completed monthly. It was also recommended that two staff signatures are obtained for debits and credits as currently only one staff member is responsible for monies. Accident records were fully detailed and the manager reviews all reports. The auditing of accidents had improved since the last visit to the home. Monthly audits take place and include any actions and outcomes and a summary is written at the end of each month. This ensures that any trends are identified and risks minimised. A recent Environmental Health Report was reviewed and it was pleasing to see that the two requirements made had been actioned and records were now Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 23 being completed as required. This shows that the home respond positively to requirements and ensure the safety of the residents. Maintenance records were reviewed and servicing had taken place for the bath hoists and hoists, legionella, portable appliances, gas appliances, fire alarms and emergency lighting. This contributes to maintaining a safe environment for residents to live in. Fire training had taken place and there was evidence of fire drills taking place to ensure that staff have the knowledge how to respond in the event of a fire, in order to safeguard the residents. Correction fluid had been used on fire records and this practice must cease. A sluice room was found to be unlocked and it was noted that cleaning products and disinfectants were stored in here; this would be a serious risk to the health of vulnerable residents if accidentally swallowed. Substances harmful to health must be stored securely at all times and an immediate requirement was made to this effect. The manager has since informed CSCI that coded locks were to be fitted to both the sluice rooms. A purple liquid had been decanted into a spray bottle and was not labelled. This could be a potential risk to residents and decanted products must be labelled to ensure that the substance can be identified. Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 2 Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) Requirement Care plans must be written in respect of aggressive or challenging behaviour. (Previous timescale of 01/02/06 not met) Behaviour charts must also be implemented to record any aggressive behaviour. Tippex correction fluid must not be used on documentation. (Previous timescale of 13/12/05 not met) Identity photographs must be available for all residents. Regular medication audits must be undertaken, and written evidence of this maintained. (Previous timescale of 31/07/05 and 06/01/06 not met) Medication quantities must be signed in upon receipt. Medicines left in stock must be carried forward. Time for activities and activities offered must be reviewed to ensure that residents are stimulated. DS0000004516.V305834.R01.S.doc Timescale for action 22/09/06 2. OP7 17 25/08/06 3. 4. OP7 OP9 17(1)(a) (2) Sch3 13(2) 25/09/06 20/10/06 5. OP9 13(2) 15/09/06 6. OP12 16(2)(n) 16/10/06 Alexandra House Version 5.2 Page 26 7. OP12 16 (2)(m)(n) 13(6) 16(2j) 23(2d) 13(4a,c) 8. 9. OP18 OP19 A log of social activities must be recorded in individual files. (Previous timescale of 01/02/06 not met) All staff must receive training on the whistle blowing policy. Dining room carpet requires a deep clean. Dining room wallpaper requires repair. 16/10/06 31/10/06 11/09/06 10. OP29 11. OP30 Carpet in conservatory requires stretching. 19 Sch 2 PoVA checks must be available on staff files and CRB checks must be available to inspectors. (The manager received this as an immediate requirement) 18(1)(a)(c Staff must fully complete )(i) induction programmes and signatures must be obtained. The Registered Manager must ensure that the induction process is in line with the Skills for Care guidance. Senior managers must review the Registered Managers current workload and identify how this can be delegated to others. Residents meetings must take place to ensure that residents and their families are given the opportunity to discuss and share any ideas or concerns about the home in an open and inclusive atmosphere. Minutes from meetings must be available. (Previous timescales of 01/09/06 and 31/01/06 not met) Regulation 26 visit reports must be written and available for review. A formal quality assurance system must be implemented at the home and quality surveys must demonstrate how the DS0000004516.V305834.R01.S.doc 01/08/06 27/10/06 12. OP31 18(1)(a) 16/10/06 13. OP32 12 (2) 24 03/11/06 14. 15. OP33 OP33 26 24 29/09/06 30/11/06 Alexandra House Version 5.2 Page 27 16. OP38 13(4)(a,c) 17. OP38 13(4)(a,c) quality of care has been reviewed and improved as a result of the survey being carried out. A report based on the findings of these surveys must be produced and accessible to all interested parties. (Previous timescale of 06/06/05, 08/11/05 & 03/03/06 not met) COSHH products must be stored 28/07/06 securely and out of residents reach. (The manager received this as an immediate requirement) Any substances, which are 31/07/06 decanted, must be clearly labelled. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP1 OP7 OP8 OP9 OP27 Good Practice Recommendations It is recommended that the service user guide and statement of purpose are available in other formats. It is recommended that some care plans are written as a summary of care It is recommended arm circumferences are recorded for residents who refuse to be weighed. It is recommended that a copy of prescriptions is kept alongside the MAR chart. Details of the arrangements for on call support for the person in charge of the shift should be recorded on the staffing rotas. The manager should have free time when she is not on call. It is recommended that two staff signatures are obtained for transactions on resident’s personal monies and audits are completed monthly. 6. OP35 Alexandra House DS0000004516.V305834.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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